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The Berwick Report identifies importance for vigilance
The events at Mid-Staffordshire Hospitals sent shock waves throughout the NHS and the general public, and have focussed the minds of all of us who work in the NHS, on the fact the job of assuring and improving the safety of our patients is never finished.
The Berwick Report, published today, clearly identifies the importance of constant vigilance, monitoring and learning to make sure our patients do not come to any kind of avoidable harm. We need to actively seek out the views of patients and staff, and work hard to build a culture of openness, honesty and support so that no stone is left unturned in the pursuit of patient safety.
We have made huge improvements in patient safety in recent years. Thanks to a fantastic effort from right across the NHS, hospital rates of MRSA are 24% lower than they were in 2011, and the data we have suggests pressure ulcers are 22% lower than this time last year and the number of people hurt by a fall while being cared for has fallen 18% over the same period. Continuing these improvements will be challenging – the data does show improvement slowing over recent months – but as the Berwick report says, this is where untiring and constant endeavour is needed.
In other areas, we are working hard on commissioning a new and improved, single national reporting and learning system for incident reporting and management. This will not only encourage increased reporting and provide a more responsive system for clinicians, but more importantly, it will also improve our ability to use the data we collect to improve patient care.
We are also expanding the ‘classic’ NHS Safety Thermometer (which measures the prevalence of pressure ulcers, harm from falls, VTE and catheter associated urine infections) to make versions more specific to mental health care, medicines safety and maternity so that we can better understand where improvements are needed and make progress on delivering these.
We know and recognise that sometimes the NHS gets it wrong, and that we all need to work hard together to address concerns and problems and make sure they are put right as quickly as possible.
Because healthcare techniques continue to advance, safety is a continually-emerging property, so there is no absolute definition of “safe”. This is important to remember as we build a better culture of safety in the NHS – we have to constantly assess and improve the safety of our care, working from what our patients and staff tell us as well as our understanding of statistical data.
Professor Berwick’s excellent report shows us all how much more can be done with a united, concerted and sustained effort across all our services. His four key aims for the whole of the NHS system are:
- placing the quality of patient care, especially patient safety, above all other aims;
- engaging, empowering, and hearing patients and carers at all times;
- fostering whole-heartedly the growth and development of all staff, including their ability and support to improve the processes in which they work; and
- embracing transparency unequivocally and everywhere, in the service of accountability, trust, and the growth of knowledge.
It is difficult to argue with any of these, but we know that living by these principles in our day-to-day work is easier said than done and we must all focus on these key principles.
“Compassion in Practice”, my vision and strategy for nursing, midwifery and care, is currently in its implementation phase, and work is already going on to ensure that there are the right nursing skills, in the right place, at the right time. Analysing and understanding data and information on our own performance is key to making sure risks to patient safety are identified and resolved at the first available opportunity – a culture of learning and transparency is a key theme running through both the Berwick Report and last month’s Keogh Review.
Listening closely to our patients will give us some of the most important information and data at organisational and departmental level. Also, fully engaging with them on a one-to-one level is vital in ensuring that we understand the unique circumstances and histories of each patient, can clearly identify their individual risks of harm, and take individual action to protect them.
Like Professor Berwick, I firmly believe and my experience as CNO reinforces, that almost all NHS staff want to do their very best for patients and ensure they are kept safe from harm. We know there are a minority of cases where clinicians have shown a truly callous disregard for their patients’ safety and comfort, and I am in complete agreement with him that those who intentionally neglect patients should face the consequences.
But in most cases, nurses, midwives and all care staff are doing the very best they can in often-challenging situations. Within Compassion in Practice, I have developed the “6Cs”: care, compassion, competence, communication, courage and commitment. They are all equally important, but here, courage is of vital importance. All NHS staff, not just nurses, need to have the courage to speak up when they see something wrong, and in turn senior leaders must ensure their staff are confident they will be listened to.
As the NHS beds into its new structure, we have a fantastic opportunity to make our NHS the safest healthcare system in the world. It will be hard work that will require each and every one of us to put our foot on the accelerator and never ease off. I have every confidence we can do it.